The Silent Spread: A Case of Disseminated Tuberculosis in an Immunocompetent Patient

Abstract Introduction: Disseminated tuberculosis is a rare condition that usually occurs in immunocompromised hosts such as those with HIV, malignancy, or post-transplant. The disease is characterized by widespread multi-organ system involvement (1). Clinical presentation may vary and mimic other clinical conditions, making diagnosis challenging. We present a case of a young immunocompetent man who presented with disseminated tuberculosis. Case: A 41-year-old migrant from Senegal came to the ED for generalized fatigue, productive cough of blood-tinged sputum, night sweats, chills, flank pain, and unintentional weight loss for 2 months. He emigrated a year ago, lives in a shelter, and has no travel history. On presentation, he was tachycardic to 145. All other vitals were normal. Physical exam was pertinent for dry oral mucosa, poor skin turgor, increased tactile and auscultatory vocal fremitus on the right lung field, and left upper quadrant tenderness without guarding. Laboratory results show a white cell count of 10.85 x19(3)/MCL, neutrophils of 76.8%, hemoglobin of 10.6 g/dL, platelets of 483, and lactate of 6.7. Plain film of the chest showed diffuse granular opacities not present in a film 4 months prior. Further imaging showed randomly distributed ill-defined nodules with a small cavitary lesion in the right upper lobe. He also had mediastinal and axillary lymphadenopathies and patchy areas of cortical or wedge-shaped hypodensities within the renal parenchyma. The patient was managed as a case of undifferentiated sepsis secondary to suspected disseminated tuberculosis. He was given fluids and started on broad-spectrum antibiotics. Fungal workup and HIV returned negative. Sputum acid-fast bacilli return positive. Urine studies showed sterile pyuria of 26.8/HPF, and a positive acid-fast bacilli. He was started on anti-tuberculous therapy with Rifampin, Isoniazid, Pyrazinamide, and Ethambutol therapy. Discussion: In 2023, the incidence of tuberculosis in the United States was 2.5 per 100,000. In New York City, the incidence is more than double at 6.1 per 100,000. Given his risk factors of immigration and shelter placement, pulmonary tuberculosis was the top differential. He however presented with a severe disseminated disease despite being immunocompetent with extrapulmonary signs and symptoms which made it challenging. Disseminated disease is a serious condition that warrants high clinical suspicion even in immunocompetent hosts, as early detection and intervention can alter disease outcome and recovery. References: 1. Y Ye, N Yang, J Zhou, G Qian, J Chu “Case report: Metagenomic Next-Generation Sequencing in Diagnosis of Disseminated Tuberculosis of an Immunocompetent Patient”, Front Med (Lausanne). 2. https://www.nyc.gov/site/doh/about/press/pr2023/world-tb-day-2023 [asterisk][asterisk]